Pub Date : 2012-04-01DOI: 10.1016/j.amjopharm.2012.02.002
Timothy Reilly PharmD, BCPS, CGP, FASCP , David Barile MD , Stanley Reuben RPh, MBA
Background
The prevalence of prescription medication use increases with age, and older adults are at increased risk of harm from medication use.
Objective
To describe the role of a pharmacist on a General Medicine Acute Care of the Elderly (GM-ACE) Unit.
Methods
A job description was prepared, and a clinical pharmacist specializing in internal medicine was re-assigned to participate in multidisciplinary rounds on the ACE unit twice weekly and to work with a unit-based pharmacist assigned to multiple units. The clinical pharmacist also provided formal education on geriatric pharmacotherapy for other health care providers. Interventions were defined as changes in the medical record and provision of drug information. Interventions were tracked with an existing form and sorted by category. Data on interventions were presented to the pharmacy and therapeutics committee routinely.
Results
After 3 months, the clinical pharmacist accomplished 76 interventions in the areas of agent selection, dose optimization, addition of therapy, deletion of therapy, medication reconciliation, intravenous to oral conversion, technology improvements, and drug information/patient education.
Conclusion
Expanding the role of the pharmacist in a GM-ACE unit has improved the medication use process in a high-risk population through improvements in medication overuse, medication underuse, dosing, medication reconciliation, patient education, and health care provider education.
{"title":"Role of the Pharmacist on a General Medicine Acute Care for the Elderly Unit","authors":"Timothy Reilly PharmD, BCPS, CGP, FASCP , David Barile MD , Stanley Reuben RPh, MBA","doi":"10.1016/j.amjopharm.2012.02.002","DOIUrl":"10.1016/j.amjopharm.2012.02.002","url":null,"abstract":"<div><h3>Background</h3><p>The prevalence of prescription medication use increases with age, and older adults are at increased risk of harm from medication use.</p></div><div><h3>Objective</h3><p>To describe the role of a pharmacist on a General Medicine Acute Care of the Elderly (GM-ACE) Unit.</p></div><div><h3>Methods</h3><p>A job description was prepared, and a clinical pharmacist specializing in internal medicine<span><span><span><span> was re-assigned to participate in multidisciplinary rounds on the ACE unit twice weekly and to work with a unit-based pharmacist assigned to multiple units. The clinical pharmacist also provided formal education on geriatric </span>pharmacotherapy for other health care providers. Interventions were defined as changes in the </span>medical record and provision of </span>drug information. Interventions were tracked with an existing form and sorted by category. Data on interventions were presented to the pharmacy and therapeutics committee routinely.</span></p></div><div><h3>Results</h3><p>After 3 months, the clinical pharmacist accomplished 76 interventions in the areas of agent selection, dose optimization, addition of therapy, deletion of therapy, medication reconciliation, intravenous to oral conversion, technology improvements, and drug information/patient education.</p></div><div><h3>Conclusion</h3><p>Expanding the role of the pharmacist in a GM-ACE unit has improved the medication use process in a high-risk population through improvements in medication overuse, medication underuse, dosing, medication reconciliation, patient education, and health care provider education.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 2","pages":"Pages 95-100"},"PeriodicalIF":0.0,"publicationDate":"2012-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.02.002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30503864","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-04-01DOI: 10.1016/j.amjopharm.2012.01.003
Annemie Somers PharmD , Louise Mallet PharmD , Tischa van der Cammen MD, PhD , Hugo Robays PharmD , Mirko Petrovic MD, PhD
Background
High drug consumption by older patients and the presence of many drug-related problems require careful assessment of drug therapy, for which a structured approach is recommended.
Objective
The purpose of our study was to evaluate the applicability of an adapted version of the Medication Appropriateness Index (MAI) in 50 geriatric inpatients at the time of admission.
Methods
We reviewed, for 432 prescribed drugs, indication, right choice, dosage, directions, drug–disease interactions, drug–drug interactions, and duration of therapy. In addition, adverse drug reactions were evaluated, resulting in 8 questions per drug. MAI scores were attributed independently by a geriatrician and by a clinical pharmacist, and differences between them were assessed. Furthermore, the relationship between MAI score and drug-related hospital admission was explored.
Results
Mean summed MAI scores of 13.7 according to the geriatrician and 13.6 according to the pharmacist were obtained. The highest scores were found for drugs for the central nervous and the urinary tract system; the highest scores per question were detected for right choice, adverse drug reactions, and drug–drug interactions. A good agreement between the scores of the geriatrician and the pharmacist was found: intraclass correlation coefficient was 0.91 and overall κ value was 0.71. A significantly higher MAI score was found for drug-related hospital admissions (P = 0.04 for the geriatrician and P = 0.03 for the pharmacist).
Conclusions
This adapted MAI score seems useful for detection of drug-related problems in geriatric inpatients and reliable with a low inter-rater variability and positive correlation between high score and drug-related hospital admission. We consider further application of the adapted MAI for teaching and training of clinical pharmacists, and as a systematic approach for detection of drug-related problems by the clinical pharmacists in our hospital.
{"title":"Applicability of an Adapted Medication Appropriateness Index for Detection of Drug-Related Problems in Geriatric Inpatients","authors":"Annemie Somers PharmD , Louise Mallet PharmD , Tischa van der Cammen MD, PhD , Hugo Robays PharmD , Mirko Petrovic MD, PhD","doi":"10.1016/j.amjopharm.2012.01.003","DOIUrl":"10.1016/j.amjopharm.2012.01.003","url":null,"abstract":"<div><h3>Background</h3><p>High drug consumption by older patients and the presence of many drug-related problems require careful assessment of drug therapy, for which a structured approach is recommended.</p></div><div><h3>Objective</h3><p>The purpose of our study was to evaluate the applicability of an adapted version of the Medication Appropriateness Index<span> (MAI) in 50 geriatric inpatients at the time of admission.</span></p></div><div><h3>Methods</h3><p>We reviewed, for 432 prescribed drugs, indication, right choice, dosage, directions, drug–disease interactions, drug–drug interactions, and duration of therapy. In addition, adverse drug reactions were evaluated, resulting in 8 questions per drug. MAI scores were attributed independently by a geriatrician and by a clinical pharmacist, and differences between them were assessed. Furthermore, the relationship between MAI score and drug-related hospital admission was explored.</p></div><div><h3>Results</h3><p><span>Mean summed MAI scores of 13.7 according to the geriatrician and 13.6 according to the pharmacist were obtained. The highest scores were found for drugs for the central nervous and the urinary tract system; the highest scores per question were detected for right choice, adverse drug reactions, and drug–drug interactions. A good agreement between the scores of the geriatrician and the pharmacist was found: intraclass correlation coefficient was 0.91 and overall κ value was 0.71. A significantly higher MAI score was found for drug-related hospital admissions (</span><em>P</em> = 0.04 for the geriatrician and <em>P =</em> 0.03 for the pharmacist).</p></div><div><h3>Conclusions</h3><p>This adapted MAI score seems useful for detection of drug-related problems in geriatric inpatients and reliable with a low inter-rater variability and positive correlation between high score and drug-related hospital admission. We consider further application of the adapted MAI for teaching and training of clinical pharmacists, and as a systematic approach for detection of drug-related problems by the clinical pharmacists in our hospital.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 2","pages":"Pages 101-109"},"PeriodicalIF":0.0,"publicationDate":"2012-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.01.003","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30436291","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-04-01DOI: 10.1016/j.amjopharm.2012.03.002
Zachary A. Marcum PharmD, MS , Joseph T. Hanlon PharmD, MS
{"title":"Commentary on the New American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults","authors":"Zachary A. Marcum PharmD, MS , Joseph T. Hanlon PharmD, MS","doi":"10.1016/j.amjopharm.2012.03.002","DOIUrl":"10.1016/j.amjopharm.2012.03.002","url":null,"abstract":"","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 2","pages":"Pages 151-159"},"PeriodicalIF":0.0,"publicationDate":"2012-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.03.002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30558051","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-04-01DOI: 10.1016/j.amjopharm.2012.01.001
Richard D. Boyce PhD , Steven M. Handler MD, PhD , Jordan F. Karp MD , Joseph T. Hanlon PharmD, MS
Background
Antidepressants are among the most commonly prescribed psychotropic agents for older patients. Little is known about the best source of pharmacotherapy information to consult about key factors necessary to safely prescribe these medications to older patients.
Objective
The objective of this study was to synthesize and contrast information in the package insert (PI) with information found in the scientific literature about age-related changes of antidepressants in systemic clearance and potential pharmacokinetic drug–drug interactions (DDIs).
Methods
A comprehensive search of two databases (MEDLINE and EMBASE from January 1, 1975 to September 30, 2011) with the use of a combination of search terms (antidepressants, pharmacokinetics, and drug interactions) was conducted to identify relevant English language articles. This information was independently reviewed by two researchers and synthesized into tables. These same two researchers examined the most up-to-date PIs for the 26 agents available at the time of the study to abstract quantitative information about age-related decline in systemic clearance and potential DDIs. The agreement between the two information sources was tested with κ statistics.
Results
The literature reported age-related clearance changes for 13 antidepressants, whereas the PIs only had evidence about 4 antidepressants (κ < 0.4). Similarly, the literature identified 45 medications that could potentially interact with a specific antidepressant, whereas the PIs only provided evidence about 12 potential medication–antidepressant DDIs (κ < 0.4).
Conclusion
The evidence-based literature compared with PIs is the most complete pharmacotherapy information source about both age-related clearance changes and pharmacokinetic DDIs with antidepressants. Future rigorously designed observational studies are needed to examine the combined risk of antidepressants with age-related decline in clearance and potential DDIs on important health outcomes such as falls and fractures in older patients.
{"title":"Age-Related Changes in Antidepressant Pharmacokinetics and Potential Drug-Drug Interactions: A Comparison of Evidence-Based Literature and Package Insert Information","authors":"Richard D. Boyce PhD , Steven M. Handler MD, PhD , Jordan F. Karp MD , Joseph T. Hanlon PharmD, MS","doi":"10.1016/j.amjopharm.2012.01.001","DOIUrl":"10.1016/j.amjopharm.2012.01.001","url":null,"abstract":"<div><h3>Background</h3><p>Antidepressants are among the most commonly prescribed psychotropic agents<span> for older patients. Little is known about the best source of pharmacotherapy information to consult about key factors necessary to safely prescribe these medications to older patients.</span></p></div><div><h3>Objective</h3><p>The objective of this study was to synthesize and contrast information in the package insert (PI) with information found in the scientific literature about age-related changes of antidepressants in systemic clearance and potential pharmacokinetic drug–drug interactions (DDIs).</p></div><div><h3>Methods</h3><p>A comprehensive search of two databases (MEDLINE and EMBASE from January 1, 1975 to September 30, 2011) with the use of a combination of search terms (<em>antidepressants</em>, <em>pharmacokinetics</em>, and <span><em>drug</em><em> interactions</em></span><span>) was conducted to identify relevant English language articles. This information was independently reviewed by two researchers and synthesized into tables. These same two researchers examined the most up-to-date PIs for the 26 agents available at the time of the study to abstract quantitative information about age-related decline in systemic clearance and potential DDIs<span>. The agreement between the two information sources was tested with κ statistics.</span></span></p></div><div><h3>Results</h3><p>The literature reported age-related clearance changes for 13 antidepressants, whereas the PIs only had evidence about 4 antidepressants (κ < 0.4). Similarly, the literature identified 45 medications that could potentially interact with a specific antidepressant, whereas the PIs only provided evidence about 12 potential medication–antidepressant DDIs (κ < 0.4).</p></div><div><h3>Conclusion</h3><p>The evidence-based literature compared with PIs is the most complete pharmacotherapy information source about both age-related clearance changes and pharmacokinetic DDIs with antidepressants. Future rigorously designed observational studies are needed to examine the combined risk of antidepressants with age-related decline in clearance and potential DDIs on important health outcomes such as falls and fractures in older patients.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 2","pages":"Pages 139-150"},"PeriodicalIF":0.0,"publicationDate":"2012-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.01.001","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30420435","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-02-01DOI: 10.1016/j.amjopharm.2011.12.002
Herbert S.B. Baraf MD , Morris S. Gold ScD , Richard A. Petruschke PharmD , Matthew S. Wieman MD
Background
Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with a dose-related risk of cardiovascular, renal, and gastrointestinal adverse events (AEs). Topical NSAIDs produce lower systemic NSAID exposure compared with oral NSAIDs, offering potential benefits.
Objective
To evaluate the safety of topical diclofenac sodium 1% gel (DSG) for knee and hand osteoarthritis (OA) in older and younger patients and in patients with versus without comorbid hypertension, type 2 diabetes, or cerebrovascular or cardiovascular disease.
Methods
Post hoc analysis of pooled data from 5 randomized, double-blind, placebo-controlled trials involving 1426 patients (aged ≥35 years) with mild to moderate OA of the knee and 783 patients (aged ≥40 years) with mild to moderate OA of the hand. Patients applied 4 g of DSG or vehicle to affected knees QID for 12 weeks or 2 g of DSG or vehicle to affected hands QID for 8 weeks.
Results
In patients with knee OA, the percentage with ≥1 adverse event was similar in patients aged <65 years (56.6%) versus ≥65 years (55.8%) and was similar in patients with versus without comorbid hypertension (53.4% vs 59.0%, respectively), type 2 diabetes mellitus (50.0% vs 57.2%), or cerebrovascular or cardiovascular disease (53.8% vs 56.5%). In patients with hand OA, the percentage with ≥1 AE was similar in patients aged ≥65 years (42.7%) versus <65 years (39.1%) and was similar in patients with versus without hypertension (39.6% vs 41.7%, respectively), lower in patients with versus without type 2 diabetes mellitus (28.0% vs 41.6%), and higher in patients with versus without cerebrovascular or cardiovascular disease (48.5% vs 39.2%). Gastrointestinal, cardiovascular, and renal AEs were rare and did not differ according to age or comorbidity. Application site reactions were the primary cause for the greater frequency of AEs with DSG versus vehicle.
Conclusion
The similar and low rates of AEs in DSG-treated patients aged ≥65 years and <65 years and in those with and without comorbid hypertension, type 2 diabetes, or cerebrovascular or cardiovascular disease suggest that DSG treatment is generally well tolerated.
背景:非甾体抗炎药(NSAIDs)与心血管、肾脏和胃肠道不良事件(ae)的剂量相关风险相关。与口服非甾体抗炎药相比，外用非甾体抗炎药产生更低的全身暴露，提供潜在的益处。目的评价外用1%双氯芬酸钠凝胶(DSG)治疗老年和年轻患者以及合并高血压、2型糖尿病或脑血管或心血管疾病患者膝和手骨关节炎(OA)的安全性。方法对5项随机、双盲、安慰剂对照试验的汇总数据进行回顾性分析，这些试验涉及1426例(年龄≥35岁)轻度至中度膝关节炎患者和783例(年龄≥40岁)轻度至中度手部OA患者。患者在患膝QID处应用4 g DSG或载药12周，或在患手QID处应用2 g DSG或载药8周。结果在膝关节OA患者中，65岁(56.6%)与≥65岁(55.8%)患者发生≥1次不良事件的比例相似，合并高血压(53.4% vs 59.0%)、2型糖尿病(50.0% vs 57.2%)、脑血管或心血管疾病(53.8% vs 56.5%)患者的不良事件发生率相似。在手部OA患者中，≥65岁的患者(42.7%)与65岁的患者(39.1%)发生≥1次AE的比例相似，有高血压的患者与没有高血压的患者相似(分别为39.6%与41.7%)，有2型糖尿病的患者与没有2型糖尿病的患者相似(28.0%与41.6%)，有脑血管或心血管疾病的患者相似(48.5%与没有心血管疾病的患者相似)。胃肠道、心血管和肾脏不良反应很少见，且不因年龄或合并症而异。应用部位反应是DSG比载药组更频繁发生ae的主要原因。结论≥65岁、≥65岁、合并或不合并高血压、2型糖尿病、脑血管或心血管疾病的患者中，DSG治疗的不良反应发生率相似且较低，表明DSG治疗总体耐受良好。
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Pub Date : 2012-02-01DOI: 10.1016/j.amjopharm.2012.01.004
Carolyn T. Thorpe PhD, MPH , Holly C. Lassila DrPH , Christine K. O'Neil PharmD , Joshua M. Thorpe PhD, MPH , Joseph T. Hanlon PharmD, MS , Robert L. Maher Jr PharmD
{"title":"Reconsideration of Key Articles Regarding Medication-Related Problems in Older Adults from 2011","authors":"Carolyn T. Thorpe PhD, MPH , Holly C. Lassila DrPH , Christine K. O'Neil PharmD , Joshua M. Thorpe PhD, MPH , Joseph T. Hanlon PharmD, MS , Robert L. Maher Jr PharmD","doi":"10.1016/j.amjopharm.2012.01.004","DOIUrl":"10.1016/j.amjopharm.2012.01.004","url":null,"abstract":"","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 1","pages":"Pages 2-13"},"PeriodicalIF":0.0,"publicationDate":"2012-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.01.004","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30456270","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-02-01DOI: 10.1016/j.amjopharm.2011.12.001
Parinaz K. Ghaswalla PhD, Spencer E. Harpe PharmD, PhD, MPH, Patricia W. Slattum PharmD, PhD
Background
Practice guidelines recommend anticoagulation therapy with warfarin for stroke prevention in patients with atrial fibrillation (AF). Despite this, warfarin is underused in older adults.
Objective
The purpose of this study was to determine the prevalence of AF in nursing home (NH) residents and the use of warfarin or other antiplatelet medications in NH residents with AF who have indications for and no contraindications against warfarin use. The secondary objective was to determine the factors associated with warfarin use in NH residents with AF.
Methods
Cross-sectional analysis of prescription and resident data files from the 2004 National Nursing Home Survey was performed. Residents with a diagnosis of AF were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, and prescriptions of warfarin and antiplatelet medications were identified using Long-Term Care Drug Database System (LTCDDS) codes. Resident characteristics, stroke risk factors, and potential bleeding risk factors significant at P < 0.10 in χ2 analyses were entered in the final multiple logistic regression model to determine the factors associated with warfarin use.
Results
From 13,507 NH residents, 1904 (14%) had a diagnosis of AF and 1767 (13%) had a diagnosis of AF with indications for and no contraindications against warfarin use. Of these 1767 residents, 537 (30%) were prescribed warfarin, and of the remaining 1230 residents who were not prescribed warfarin, 283 (23%) received either aspirin or clopidogrel. Thus, of 1767 residents with AF, with indications for and no contraindications to warfarin use, 947 (54%) residents did not receive any antithrombotic therapy in the form of warfarin, aspirin, clopidogrel, or a combination of these medications. Factors that were significantly associated with increased odds of receiving warfarin were congestive heart failure, previous stroke or transient ischemic attack, deep vein thrombosis or peripheral embolus, valvular heart disease, and total number of medications ≥6. Factors that were significantly associated with reduced odds of receiving warfarin were nonwhite race, history of gastrointestinal bleeding, and use of antiplatelets (ie, clopidogrel).
Conclusions
AF is common in NH residents, and more than half of the residents with AF who had indications for and no contraindications against warfarin use were not prescribed either warfarin or antiplatelets, such as aspirin or clopidogrel, suggesting that antithrombotic therapy may be underused in NH residents with AF.
{"title":"Warfarin Use in Nursing Home Residents: Results from the 2004 National Nursing Home Survey","authors":"Parinaz K. Ghaswalla PhD, Spencer E. Harpe PharmD, PhD, MPH, Patricia W. Slattum PharmD, PhD","doi":"10.1016/j.amjopharm.2011.12.001","DOIUrl":"10.1016/j.amjopharm.2011.12.001","url":null,"abstract":"<div><h3>Background</h3><p><span>Practice guidelines recommend anticoagulation therapy with warfarin for stroke prevention </span>in patients<span> with atrial fibrillation (AF). Despite this, warfarin is underused in older adults.</span></p></div><div><h3>Objective</h3><p>The purpose of this study was to determine the prevalence of AF in nursing home (NH) residents and the use of warfarin or other antiplatelet medications in NH residents with AF who have indications for and no contraindications against warfarin use. The secondary objective was to determine the factors associated with warfarin use in NH residents with AF.</p></div><div><h3>Methods</h3><p>Cross-sectional analysis of prescription and resident data files from the 2004 National Nursing Home Survey was performed. Residents with a diagnosis of AF were identified using <span><em>International Classification of Diseases</em><em>, Ninth Revision, Clinical Modification</em></span> (ICD-9-CM) codes, and prescriptions of warfarin and antiplatelet medications were identified using Long-Term Care Drug Database System (LTCDDS) codes. Resident characteristics, stroke risk factors, and potential bleeding risk factors significant at <em>P</em> < 0.10 in χ<sup>2</sup><span> analyses were entered in the final multiple logistic regression model to determine the factors associated with warfarin use.</span></p></div><div><h3>Results</h3><p><span>From 13,507 NH residents, 1904 (14%) had a diagnosis of AF and 1767 (13%) had a diagnosis of AF with indications for and no contraindications against warfarin use. Of these 1767 residents, 537 (30%) were prescribed warfarin, and of the remaining 1230 residents who were not prescribed warfarin, 283 (23%) received either aspirin<span><span><span> or clopidogrel. Thus, of 1767 residents with AF, with indications for and no contraindications to warfarin use, 947 (54%) residents did not receive any </span>antithrombotic therapy in the form of warfarin, aspirin, clopidogrel, or a combination of these medications. Factors that were significantly associated with increased odds of receiving warfarin were </span>congestive heart failure<span><span><span>, previous stroke or transient ischemic attack<span>, deep vein thrombosis or peripheral </span></span>embolus, </span>valvular heart disease, and total number of medications ≥6. Factors that were significantly associated with reduced odds of receiving warfarin were nonwhite race, history of </span></span></span>gastrointestinal bleeding, and use of antiplatelets (ie, clopidogrel).</p></div><div><h3>Conclusions</h3><p>AF is common in NH residents, and more than half of the residents with AF who had indications for and no contraindications against warfarin use were not prescribed either warfarin or antiplatelets, such as aspirin or clopidogrel, suggesting that antithrombotic therapy may be underused in NH residents with AF.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 1","pages":"Pages 25-36.e2"},"PeriodicalIF":0.0,"publicationDate":"2012-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.12.001","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30371639","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-02-01DOI: 10.1016/j.amjopharm.2011.12.004
Vicki R. Kee PharmD, BCPS
Background
Clostridium difficile is a main cause of health care-associated infections. The incidence and severity have been increasing. Elderly persons are at an increased risk of morbidity and mortality from C. difficile infection (CDI). Relatively few advances have been made in the treatment of CDI since it was first identified as a cause of antibiotic-associated diarrhea more than 30 years ago.
Objective
This article reviews CDI and provides an update on its treatment, including recently published clinical practice guidelines and the recently approved drug, fidaxomicin.
Methods
English-language literature was identified through a search of PubMed (1966–October 2011), Iowa Drug Information Service (1966–October 2011), and International Pharmaceutical Abstracts (1970–October 2011). Key search terms included Clostridium difficile, Clostridium infections, pseudomembranous colitis, antibiotic-associated diarrhea, Clostridium difficile-associated diarrhea, elderly, geriatric, epidemiology, microbiology, diagnosis, risk factors, treatment, drug therapy, vancomycin, metronidazole, and fidaxomicin.
Results
Metronidazole and vancomycin remain the mainstays of CDI treatment. Current guidelines recommend oral metronidazole for initial mild to moderate episodes or first recurrence. Oral vancomycin is recommended for initial severe episodes, or first or second recurrence. Fidaxomicin was approved in 2011 for treatment of CDI, but its place in therapy has yet to be determined. Other antibiotics have been used with variable success. Saccharomyces boulardii is the only probiotic that has shown efficacy in CDI. Fecal transplants have been used successfully in some patients, but randomized studies are needed. Immune therapy with a vaccine and monoclonal antibodies is being studied in clinical trials.
Conclusions
Treatment of CDI is challenging due to the limited number of drugs that have proven to be effective, concerns about antibiotic resistance, and recurring disease. The recent approval of fidaxomicin provides a new alternative. Immune therapy will likely play a greater role in the future.
背景艰难梭菌是卫生保健相关感染的主要原因。发病率和严重程度一直在增加。老年人因艰难梭菌感染(CDI)而发病和死亡的风险增加。自从30多年前CDI首次被确定为抗生素相关性腹泻的原因以来，在治疗CDI方面取得的进展相对较少。本文综述了CDI并提供了其治疗的最新进展，包括最近发表的临床实践指南和最近批准的药物fidaxomicin。方法检索PubMed(1966—2011年10月)、Iowa Drug Information Service(1966—2011年10月)和International Pharmaceutical Abstracts(1970—2011年10月)的英文文献。关键搜索词包括艰难梭菌、梭菌感染、假膜性结肠炎、抗生素相关性腹泻、艰难梭菌相关性腹泻、老年人、老年病学、流行病学、微生物学、诊断、危险因素、治疗、药物治疗、万古霉素、甲硝唑和非达霉素。结果甲硝唑和万古霉素仍是治疗CDI的主要药物。目前的指南推荐口服甲硝唑用于轻度至中度的初始发作或首次复发。对于最初的严重发作，或第一次或第二次复发，建议口服万古霉素。2011年，非达索霉素被批准用于治疗CDI，但其在治疗中的地位尚未确定。其他抗生素的使用取得了不同程度的成功。博拉氏酵母菌是唯一对CDI有效的益生菌。粪便移植已经在一些患者身上成功应用，但还需要随机研究。目前正在临床试验中研究疫苗和单克隆抗体的免疫疗法。结论CDI的治疗具有挑战性，因为已被证明有效的药物数量有限，并且存在抗生素耐药性和疾病复发的问题。最近批准的非达霉素提供了一个新的选择。免疫疗法在未来可能会发挥更大的作用。
{"title":"Clostridium Difficile Infection in Older Adults: A Review and Update on Its Management","authors":"Vicki R. Kee PharmD, BCPS","doi":"10.1016/j.amjopharm.2011.12.004","DOIUrl":"10.1016/j.amjopharm.2011.12.004","url":null,"abstract":"<div><h3>Background</h3><p><span><em>Clostridium difficile</em></span> is a main cause of health care-associated infections. The incidence and severity have been increasing. Elderly persons are at an increased risk of morbidity and mortality from <em>C. difficile</em><span> infection (CDI). Relatively few advances have been made in the treatment of CDI since it was first identified as a cause of antibiotic-associated diarrhea more than 30 years ago.</span></p></div><div><h3>Objective</h3><p>This article reviews CDI and provides an update on its treatment, including recently published clinical practice guidelines and the recently approved drug<span>, fidaxomicin.</span></p></div><div><h3>Methods</h3><p>English-language literature was identified through a search of PubMed (1966–October 2011), Iowa Drug Information Service (1966–October 2011), and International Pharmaceutical Abstracts (1970–October 2011). Key search terms included <em>Clostridium difficile</em>, <span><em>Clostridium infections</em></span>, <span><em>pseudomembranous colitis</em></span>, <em>antibiotic-associated diarrhea</em>, <em>Clostridium difficile-associated diarrhea</em>, <span><em>elderly, </em><em>geriatric</em><em>, epidemiology</em></span>, <em>microbiology</em>, <em>diagnosis</em>, <em>risk factors</em>, <em>treatment</em>, <span><span><em>drug therapy, </em><em>vancomycin</em><em>, </em></span><em>metronidazole</em><em>,</em></span> and <em>fidaxomicin</em>.</p></div><div><h3>Results</h3><p>Metronidazole and vancomycin remain the mainstays of CDI treatment. Current guidelines recommend oral metronidazole for initial mild to moderate episodes or first recurrence. Oral vancomycin is recommended for initial severe episodes, or first or second recurrence. Fidaxomicin was approved in 2011 for treatment of CDI, but its place in therapy has yet to be determined. Other antibiotics have been used with variable success. <span><em>Saccharomyces boulardii</em></span><span><span><span> is the only probiotic that has shown efficacy in CDI. </span>Fecal transplants<span> have been used successfully in some patients, but randomized studies are needed. Immune therapy<span> with a vaccine and monoclonal antibodies is being studied in </span></span></span>clinical trials.</span></p></div><div><h3>Conclusions</h3><p>Treatment of CDI is challenging due to the limited number of drugs that have proven to be effective, concerns about antibiotic resistance, and recurring disease. The recent approval of fidaxomicin provides a new alternative. Immune therapy will likely play a greater role in the future.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 1","pages":"Pages 14-24"},"PeriodicalIF":0.0,"publicationDate":"2012-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.12.004","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30399225","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-02-01DOI: 10.1016/j.amjopharm.2011.11.003
Gail B. Rattinger PharmD, PhD , Sarah K. Dutcher BS , Pankdeep T. Chhabra MBBS, MPH , Christine S. Franey MPH , Linda Simoni-Wastila BSPharm, PhD , Stephen S. Gottlieb MD , Bruce Stuart PhD , Ilene H. Zuckerman PharmD, PhD
Background
Alzheimer's disease and related disorders (ADRD) are prevalent in older adults, increase the costs of chronic heart failure (CHF) management, and may be associated with undertreatment of cardiovascular disease.
Objective
The purpose of our study was to determine the relationship between comorbid ADRD and CHF medication use and adherence among Medicare beneficiaries with CHF.
Methods
This 2-year (1/1/2006–12/31/2007) cross-sectional study used data from the Chronic Condition Data Warehouse of the Centers for Medicare and Medicaid Services. Medicare beneficiaries with evidence of CHF who had systolic dysfunction and Medicare Parts A, B, and D coverage during the entire study period were included. ADRD was identified based on diagnostic codes using the Chronic Condition Data Warehouse algorithm. CHF evidence-based medications (EBMs) were selected based on published guidelines: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, selected β-blockers, aldosterone antagonists, and selected vasodilators. Measures of EBMs included a binary indicator of EBM use and medication possession ratio among users.
Results
Of 9827 beneficiaries with CHF and systolic dysfunction, 24.2% had a diagnosis of ADRD. Beneficiaries with ADRD were older (80.8 vs 73.6 years; P < 0.0001) and more likely to be female (69.3% vs 58.1%; P < 0.0001). Overall EBM use was lower in patients with CHF and ADRD compared with patients with CHF but no ADRD (85.3% vs 91.2%; P < 0.0001). Lower use among those with ADRD was consistent across all EBM classes except vasodilators. Among beneficiaries receiving EBM, those with ADRD had a slightly higher mean medication possession ratio for EBM compared with those without ADRD (0.86 vs 0.84; P = 0.0001).
Conclusions
EBM medication adherence was high in this population, regardless of ADRD status. However, patients with ADRD had lower EBM use compared with those without ADRD. Low use of specific EBM medications such as β-blockers was found in both groups. Therefore, interventions targeting increased treatment with specific EBMs for CHF, even among patients with ADRD, may be of benefit and could help reduce CHF-related hospitalizations.
背景:阿尔茨海默病及相关疾病(ADRD)在老年人中普遍存在，增加了慢性心力衰竭(CHF)治疗的成本，并可能与心血管疾病治疗不足有关。目的本研究的目的是确定CHF医疗保险受益人中共病性ADRD与CHF药物使用和依从性之间的关系。方法这项为期2年(2006年1月1日- 2007年12月31日)的横断面研究使用的数据来自美国联邦医疗保险和医疗补助服务中心的慢性病数据仓库。在整个研究期间，有收缩期功能障碍的CHF证据的医疗保险受益人和医疗保险A、B和D部分的覆盖范围被纳入。采用慢性病数据仓库算法，基于诊断代码对ADRD进行识别。根据已发表的指南选择CHF循证药物(EBMs):血管紧张素转换酶抑制剂、血管紧张素受体阻滞剂、选定β受体阻滞剂、醛固酮拮抗剂和选定血管扩张剂。循证医学的测量包括循证医学使用和使用者药物持有率的二元指标。结果9827例CHF合并收缩功能障碍患者中，24.2%诊断为ADRD。患有ADRD的受益人年龄较大(80.8岁vs 73.6岁;P & lt;0.0001)，女性的可能性更大(69.3% vs 58.1%;P & lt;0.0001)。与没有ADRD的CHF患者相比，CHF和ADRD患者的总体EBM使用率较低(85.3% vs 91.2%;P & lt;0.0001)。除血管扩张剂外，ADRD患者的低使用率在所有EBM类别中都是一致的。在接受循证治疗的受益人中，患有ADRD的人比没有ADRD的人对循证治疗的平均药物持有率略高(0.86 vs 0.84;P = 0.0001)。结论无论ADRD状况如何，该人群的sebm药物依从性较高。然而，与没有ADRD的患者相比，有ADRD的患者使用EBM的比例较低。两组均发现特异性EBM药物如β受体阻滞剂的使用率较低。因此，针对增加特定EBMs治疗CHF的干预措施，甚至在ADRD患者中，可能是有益的，并有助于减少与CHF相关的住院治疗。
{"title":"The Effect of Dementia on Medication Use and Adherence Among Medicare Beneficiaries With Chronic Heart Failure","authors":"Gail B. Rattinger PharmD, PhD , Sarah K. Dutcher BS , Pankdeep T. Chhabra MBBS, MPH , Christine S. Franey MPH , Linda Simoni-Wastila BSPharm, PhD , Stephen S. Gottlieb MD , Bruce Stuart PhD , Ilene H. Zuckerman PharmD, PhD","doi":"10.1016/j.amjopharm.2011.11.003","DOIUrl":"10.1016/j.amjopharm.2011.11.003","url":null,"abstract":"<div><h3>Background</h3><p>Alzheimer's disease and related disorders (ADRD) are prevalent in older adults, increase the costs of chronic heart failure (CHF) management, and may be associated with undertreatment of cardiovascular disease.</p></div><div><h3>Objective</h3><p>The purpose of our study was to determine the relationship between comorbid ADRD and CHF medication use and adherence among Medicare beneficiaries with CHF.</p></div><div><h3>Methods</h3><p>This 2-year (1/1/2006–12/31/2007) cross-sectional study used data from the Chronic Condition Data Warehouse of the Centers for Medicare and Medicaid Services. Medicare beneficiaries with evidence of CHF who had systolic dysfunction and Medicare Parts A, B, and D coverage during the entire study period were included. ADRD was identified based on diagnostic codes using the Chronic Condition Data Warehouse algorithm. CHF evidence-based medications (EBMs) were selected based on published guidelines: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, selected β-blockers, aldosterone antagonists, and selected vasodilators. Measures of EBMs included a binary indicator of EBM use and medication possession ratio among users.</p></div><div><h3>Results</h3><p>Of 9827 beneficiaries with CHF and systolic dysfunction, 24.2% had a diagnosis of ADRD. Beneficiaries with ADRD were older (80.8 vs 73.6 years; <em>P</em> < 0.0001) and more likely to be female (69.3% vs 58.1%; <em>P</em> < 0.0001). Overall EBM use was lower in patients with CHF and ADRD compared with patients with CHF but no ADRD (85.3% vs 91.2%; <em>P</em> < 0.0001). Lower use among those with ADRD was consistent across all EBM classes except vasodilators. Among beneficiaries receiving EBM, those with ADRD had a slightly higher mean medication possession ratio for EBM compared with those without ADRD (0.86 vs 0.84; <em>P</em> = 0.0001).</p></div><div><h3>Conclusions</h3><p>EBM medication adherence was high in this population, regardless of ADRD status. However, patients with ADRD had lower EBM use compared with those without ADRD. Low use of specific EBM medications such as β-blockers was found in both groups. Therefore, interventions targeting increased treatment with specific EBMs for CHF, even among patients with ADRD, may be of benefit and could help reduce CHF-related hospitalizations.</p></div>","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 1","pages":"Pages 69-80"},"PeriodicalIF":0.0,"publicationDate":"2012-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2011.11.003","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"30403941","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2012-02-01DOI: 10.1016/j.amjopharm.2012.01.005
Kenneth E. Schmader MD (Co-Editor-in-Chief), Joseph T. Hanlon PharmD, MS (Co-Editor-in-Chief)
{"title":"Goodbyes, Hellos, and Changes","authors":"Kenneth E. Schmader MD (Co-Editor-in-Chief), Joseph T. Hanlon PharmD, MS (Co-Editor-in-Chief)","doi":"10.1016/j.amjopharm.2012.01.005","DOIUrl":"10.1016/j.amjopharm.2012.01.005","url":null,"abstract":"","PeriodicalId":50811,"journal":{"name":"American Journal Geriatric Pharmacotherapy","volume":"10 1","pages":"Page 1"},"PeriodicalIF":0.0,"publicationDate":"2012-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1016/j.amjopharm.2012.01.005","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"101842108","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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